Washington > Statewide > Liquor Control Board > Financial
Outline Of Costs Source Of Funds And Certification LIQ 825 - Washington
| Outline Of Costs Source Of Funds And Certification Form. This is a Washington form and can be used in Financial Liquor Control Board Statewide . |
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Licensing and Regulation Division PO Box 43098 Olympia WA 98504-3098 FAX 360/753-2710 www.liq.wa.gov License No _____________________________________ Trade Name ____________________________________ UBI No ________________________________________ OUTLINE OF COSTS explaining all funds used for your CURRENT application REAL PROPERTY (land and building): Lease rental (one month + deposit, if any) OR Total purchase cost Business purchase cost (Purchase & Sale Agreement normally includes trade name, good will, equipment, inventory, corporate stock or LLC units) Cost of opening a new business (equipment, furniture, inventory) or COST TO CHANGE YOUR CURRENTLY LICENSED PREMISES. Remodeling/leasehold improvements/construction Miscellaneous fees (such as license/gambling, legal, architectural, health/city/county permits, opening and closing costs, working capital, etc) $_______________ $________________ $________________ $________________ $________________ TOTAL $________________ SOURCE OF FUNDS and CERTIFICATION for all liquor license application funds 1. SAVINGS/CHECKING/INVESTMENT ACCOUNTS: Bank/Institution Name: Bank/Institution Name: Bank/Institution Name: ______________________Account #:_________________$______________ ______________________Account #:_________________$______________ ______________________Account #:_________________$______________ Total $_________________ 2. LOANS FROM BANKS/MORTGAGE COMPANIES/CREDIT CARDS, ETC: Bank/Company Name: Bank/Company Name: Bank/Company Name: ______________________Account #:_________________$______________ ______________________Account #:_________________$______________ ______________________Account #:_________________$______________ Total $_________________ 3. CASH BORROWED, GIFTED, OR LOANED FROM A PERSONAL SOURCE: Name: Name: _________________________Relationship:_________________$_________________ _________________________Relationship:_________________$_________________ Total $_________________ 4. SALE OF PROPERTY: (Explain the type of property and the sale date. Include the property address for the sale of land.) $_________________ ________________________________________________________________________ Total 5. EXPLAIN THE SOURCE OF MONEY KEPT AT HOME: _______________________________________________________________________ Total 6. DEFERRED CONTRACTS (PROMISSORY NOTES): Contract with:____________________________________ Dollar amount $_________________ Contract with:____________________________________ Dollar amount $_________________ Total $_________________ $_________________ 7. OTHER (To include landlord improvements; non-monetary contributions such as labor & equipment) __________________________________________________________________________________________________________________ Total $_________________ Total of the Source of Funds must meet or Exceed the Outline of Costs total CERTIFICATION TOTAL $____________ I certify under penalty of perjury that all answers and statements are true, correct and complete. I understand that untruthful or misleading answers are cause for rejection of my application and/or revocation of any license granted. I hereby authorize investigation of my criminal history, financial records and other sources as necessary for licensing. PRINT NAME __________________________________________________ SIGNATURE _______________________________________________________________________________ DATE _________________ (Sole proprietor, partner, corporate officer or limited liability company manager or member) LIQ 825 -8/09 American LegalNet, Inc. www.FormsWorkFlow.com
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